Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Thursday, July 28, 2011

One of the weirdest features of political discourse in this country (and that's obviously saying a lot) is that it often seems to take place on a planet where the United States is all by itself. Approximately half of the claims that politicians make are obviously false because all you have to do is look at the world around us where their refutation is plain for all to see. As neither the corporate media nor, it seems, the whimpering, cowering, inarticulate remnants of the Democratic wing of the Democratic party ever bother to engage in this simple exercise, allow me.

I mentioned a few days ago that all you have to do to answer Grover Norquist is to point out that of the prosperous democracies, the United States has the lowest taxes and the least activist government; yet all those overtaxed, overregulated, enslaved peoples are healthier and happier than we are, have similar economic growth rates, and are manifestly as well as subjectively at least as free. The countries whose governments have been drowned in the bathtub? You really don't want to go there. QED.

Conservatives also like to argue that the reason we have such high health care costs is because people have insurance and generally low out-of-pocket costs, so they don't care about cost and overconsume. Make 'em pay, and the discipline of the market will bring down health care costs. Again, just pull your head out and look around. The countries where everybody has insurance, not just some people; and where they pay less out of pocket than we do all have lower costs and better outcomes. If you think that's logically impossible, then evidently there is something wrong with your logic. QED.

Comes now the brilliant idea that we can make health care for old folks more efficient and responsive by trashing the current communistic Medicare system and giving people vouchers to buy private insurance. As Kieke Okma and friends in the new NEJM tell us (you can't read it because you aren't a Big Professor, nah nah nah nah nah), people in the Netherlands got so excited listening to smart people over here in the U.S. that in 2006, they dumped their social insurance system administered by non-profit funds for a mandated private insurance system like they have in Switzerland (Hi Ana!) and like we will have here if the Affordable Care Act is allowed to take full effect.

Yeah yeah, the private insurers aren't allowed to turn people down for pre-existing conditions, they have to charge community rated premiums, and they get payment adjustments depending on the risk profile of their pools. It's all regulated to tamp down perverse incentives and make it equitable and accessible and all that good stuff. But:

1) This brilliant idea did not slow the growth of health care expenditures;
2) A growing number of people are failing to pay their mandated premiums;
3) Consumer choice? Hah! Four conglomerates control 90% of the market;
4) Competition among insurers would have nothing but pernicious effects so they have to be very tightly regulated with a complex bureaucracy, which is a big hassle because the government bureaucracy is always tussling with the insurance company bureaucracy.

You see, the easy way to do this is to have one government sponsored insurance pool, which means you don't have to argue with anybody, you just do what you have to do. (One bureaucracy is exactly half the trouble of two, no?) And you don't have to chase people down to pay mandated premiums, you just take it out of their taxes. Oh no, taxes! That's evil! Hey, it doesn't matter what you call it, taxes or premiums, you're still paying it. So get over it.

As Okma and friends put it, "Discussions about U.S. health care reform are often parochial, with scant attention paid to other countries' experiences." Really? Do yuh think? They go on: "It is thus surprising that in the ongoing debate over Medicare, some U.S. commentators have turned to the Netherlands as a model of regulated competition among private insurance companies." As we have just seen, it is a model well worth not emulating.

Wednesday, July 27, 2011

The country has been mesmerized now for weeks by a completely fake drama over whether the parties in Washington will find a way to compromise over raising the debt limit. The purpose of the farce has been to give John Boehner (semi)plausible deniability, but the intent has been, all along, that the debt ceiling not be raised. Apparently hardly anyone has noticed, but Michelle Bachmann has been saying all along that she will not vote to raise the debt ceiling under any circumstances; and she is laying down the requirement for Republican incumbents not to get teabagged in the primary elections and Limbaughed to death in the Faux News propaganda machine.

Q: Is there any scenario where you think it would be OK to raise the debt ceiling?

A: No. . . .

Q: If you wake up on August 3rd and the debt ceiling has not been raised, how will you feel?

A: August 3rd to me will be the same as August 2nd. I’m not looking for any kind of victory. This is not about Democrats versus Republicans. This is about the future of our country. So August 3rd, August 2nd, August 4th, it’s the same day. The Tea Party Patriots are fighting to preserve this nation for our kids and for our grandkids.

So that's it folks. That's what they want to happen. They are making two calculations here:

1) Most voters will end up perceiving that they can live without the federal activities that will end next month, proving that we don't need Big Gummint;
2) Economic catastrophe will be good for them -- just like it was for the Nazis.

As for the first, nobody from the administration has indicated what exactly they will do as the cash runs out, but knowing the loyalties of Obama's economic aides it's pretty clear the bondholders will get paid. There isn't a whole lot they can do to the military budget in the short term -- they'll obviously have to keep paying the troops and procuring supplies to sustain current operations. They could suspend payment on R&D contracts and long-term big ticket procurement -- ships, planes, tanks and whatnot -- but the contractors would likely keep working as long as they could sustain the cash flow on the assumption they'll get paid in due course, so the big Republican constituencies around those military plants won't get hurt any time soon. And if they do, they'll just blame Obama for misplaced priorities.

There's no way they can suspend Social Security and Medicare payments until they can absolutely prove that they had no choice. So what has to give? They can close all the national parks, eliminate payments to the states -- Community Development, Substance Abuse and Mental Health Services, Maternal and Child Health, other public health programs, K-12 and higher education support, Juvenile Justice (which pays for good stuff like diversion and counseling instead of locking 'em up). Hey, that'll be Tea Bag heaven and most voters won't feel any immediate impact. They probably can't stop paying Congressional salaries as long as they expect the members to come to work and, say, vote to raise the debt ceiling so the most they can do is stop paying congressional aides. That might make some of the members a little sad but it's not the end of the world. They can drastically scale back the functioning of the federal civil courts. Most voters won't really notice. They can shut down NIH, NASA, and the National Science Foundation. No problem, all those infidels believe in evolution and cosmology and other satanic scientific stuff.

This is what they want. It's the plan.

As for seizing all the levers of state power in the midst of the second Great Depression, I don't know but maybe they will.

Whether there are enough Republicans in the House who care more about the country and the future of humanity than they do about being on the general election ballot in 2012, I can't say, but it does not appear to be the case. Fasten your seat belts.

For example, 10 million people are starving right now in the horn of Africa. It's a combination of drought, civil conflict, and pervasive poverty. The United Nations news service will also tell you a bit about it, if you should happen to care. So far they've been able to raise about half of the $2 billion they need to stave off a world historic catastrophe.

I'm old enough to remember when Americans gave a damn about shit like that. Bangladesh, Biafra and what not. I'll bet if word leaked out that the U.S. has ponied up almost half of that $1 billion that's been pledged so far, the Tea Party would start howling for impeachment.

The fact is, though, that just feeding those people isn't going to solve anything. Much of the land is likely never to be arable again. We are seeing the first signs of the population displacements that are going to become commonplace in coming years as the global climate changes. Get ready.

Monday, July 25, 2011

I have a neurological disorder which causes me to fall into an unresponsive stupor every 24 hours, and to remain in that condition for up to 8 hours. During these episodes I often have colorful and elaborate hallucinations organized around bizarre story lines full of fantastic and magical events. I generally have only vague recollection of these experiences once I regain consciousness, and quickly forget about most of them entirely. It is possible to arouse me from this state, but I will likely be very grouchy if you do.

I have given up hope of even a diagnosis, let alone treatment. So I have accepted the situation and I now organize my life around it. Don't worry, I'm highly functional despite the condition.

There are several other analogous disorders, however, for which drug treatments are now available. For example:

Some people become sad at times.

There are children who do not like to sit quietly in rows for hours on end concentrating on boring tasks. They may squirm in their chairs, try to communicate with the children nearby, and even get up and walk around. This can be annoying to their teachers.

Many small children are emotionally labile. They will have a temper tantrum at one moment, and then play contentedly the next.

Other children do not always obey the order of adults and may provoke confrontation.

It is certainly a blessing that all of these diseases can now be treated, although there are side effects. Not to worry, more drugs are available to treat the side effects.

All that said, I have in fact been sick for the past couple of days which explains my absence. I am expected to survive. More shortly.

Thursday, July 21, 2011

I don't write very much about my own research here (maybe I should), but for anyone who hasn't figured it out yet I do health services research. (Check out "some guy's faculty page" on the sidebar if you want more info.) I like to tell myself that the work I do has value, that it can make the world better, and that it's worth spending a few bucks on.

If that is true, the federal government is doing you a favor by taking a little tiny bit of your tax dollar and using it to support the work of me and my colleagues. That follows because there just isn't any other evident source of funding for it. There's no obvious relationship to profit for any investors. We're producing knowledge which is pretty much entirely a public good. I have produced some products which could in principle be patented, such as software and analytic methods, but the only demand for them would be from other researchers who are also dependent on federal funding.

Oh yeah, there is an itsy bitsy teeny weeny amount of foundation funding for medical research. Once in a while the Robert Wood Johnson Foundation or the Commonwealth Fund comes up with money for the kinds of things I do, but it's a trivial fraction of the federal funding. Drug companies also drop a little bit of loose change on health services research if they think it might end up boosting sales -- for example they have an interest in promoting adherence to prescriptions, i.e. that people actually fill their prescriptions and keep doing so. But I'm more interested in seeing to it that people are treated appropriately, which could just as easily mean taking fewer pills as taking more.

Basically, without the National Institutes of Health, the enterprise of which I am a part -- the biomedical, public health and health services research at the nation's schools of medicine and public health -- is doomed. It will collapse. Current doctoral students and post-docs will never get jobs. Most current faculty will lose the jobs they have, along with their research assistants. Laboratories will go dark and gather dust. Advances in health related knowledge, understanding of ourselves, and the prevention, cure and palliation of disease will largely end.

At this moment, I am anticipating a grant award, for a project I have been developing for many years. If all goes well, I should get the notice sometime next month. This will be a decisive moment in my scholarly career, the chance for me to set out on the road to solving the important problems in the provision of health care that motivated me to enter this profession; the chance to accomplish something substantial for the benefit of people who live with chronic diseases.

Wednesday, July 20, 2011

It's unavailable to you common riffraff (and if you think I've been a tiresomeless crusader for open access, I still haven't gone as far as this guy), but there's an important story by Richard Trubo in the new JAMA. Thirteen states now have waiting lists for their AIDS Drug Assistance Programs, because they have chosen not to pay the cost of enrolling everyone who needs the program. The federal government provides more than $880 million through the Ryan White Program, but the states are expected to contribute as well.

The list of states with waiting lists probably won't surprise you: Arkansas, Louisiana, Florida, Alabama, Georgia, South Carolina, North Carolina, Virginia, Utah, Idaho, Montana, Wyoming, and Ohio. If Ohio seems a bit less obvious, let's not forget who is currently the governor of that purplish state. Right now, from 100 to 200 people are being added to these waiting lists every week.

As Trubo suggests, without quite spelling it out, this is not exactly a smart way to save money. In the first place, we now know that when people are treated with antiretroviral drugs, they are much less infectious. As a matter of fact, if everybody with HIV were treated successfully, the epidemic would come to an end. That's not likely ever to happen, but all of these untreated people represent a risk of creating new HIV infections that could be avoided.

Oh yeah -- if they don't get off the waiting list fairly soon, they will start to develop AIDS, which means they'll end up in the hospital, with opportunistic infections, which will be more expensive to treat, and they will have to get a supply of ARVs -- until of course they get better, at which point their situation is no longer an emergency and they don't have to get the drugs any more, until they get sick again, and around and around we go. That's really, really smart Tea Partiers.

Unless, of course, the people die. That will indeed save money. Maybe that's the real idea.

Tuesday, July 19, 2011

I'm back to my hobby of reading old Scientific Americans. The Sept. 1971 issue is a revelation. Forty years later, it's well worth revisiting.

It's a theme issue on the flow of energy in the terrestrial biosphere and human society. The various authors were well aware that the earth's supply of fossil fuel was limited, and that the exponential growth in fossil fuel consumption was unsustainable in any case because of various externalities. Nevertheless they were generally quite sanguine about the future because they presumed, without dissent, that nuclear power would be the solution.

The possibility of climate change caused by C02 emissions had occurred to people by then, though only writer, Chauncey Starr, mentioned it:

The combustion of fossil fuels, no matter how efficiently done, must always produce carbon dioxide. It's concentration in the atmosphere has increased from 290 PPM to 320 within the past century and may increase to 375 or 400 ppm by the year 2000. [Pretty much spot on -- it's now about 390 -- C] The mechanism for removal of CO2 is only partly understood; it is eventually absorbed by the ocean, converted into minerals, or incorporated by plants in their growth . . . Its effects while it resides in the atmosphere are not now predictable, although theoretically the increased carbon dioxide should cause a "greenhouse effect" by reducing the infrared heat loss from the earth and perhaps raising the mean global temperature one degree Celsius by the year 2000.

(In fact the temperature rise since 1970 has only been about half a degree Celsius, although it is a full degree since 1910 or so. The half-degree change is already turning out to be quite unpleasant.) On the other hand, Starr continues, suspended particulates have the opposite effect, by reflecting sunlight before it reaches the earth's surface, so "the observed temperature trends are not meaningful and the subject is not well understood." Nevertheless, if you are, or rather were, still worried:

In any case we have several decades for determining the carbon dioxide pathways in our biosphere. If carbon dioxide additions to the atmosphere are determined to be harmful, there is an ultimate but costly technological solution: we could use nuclear power to manufacture hydrogen by the electrolysis of water. Hydrogen would make an ideal fuel because its combustion yields water as an end product.

So, problem solved! Whoops, that hasn't worked out so well. I'll have more on the view from 40 years back anon.

Monday, July 18, 2011

I would humbly suggest that you explain to the people something very important, and as simple as the dew: there is a difference between saving money, and making somebody else pay. We save money when we get more for the same price, or pay less for the same amount of stuff, or don't buy stuff we don't really need. However, when you join Joe Lieberman and the Chamber of Commerce in proposing raising the eligibility age for Medicare, and all the other so-called "spending cuts" which you are apparently offering in exchange for nothing, that is not "saving money."

What it does accomplish is to compound the misfortune of illness or injury, and the burdens of growing old. Either somebody will still pay for the medical care of people age 65-66 -- specifically, they themselves, whatever they may have, or their children -- or the rest of us will just end up paying even more, although a year or two later. Or else they will die sooner, which indeed means spending less money but it is not the same thing as "saving money" because we failed to purchase what was needed. (You can save a lot of money by not paying the rent but you will end up homeless.)

We can indeed save money on health care, but this has nothing to do with cutting Medicare benefits. On the contrary.

Friday, July 15, 2011

Actually, the FES is no more crazy than the people who have successfully established the basic premises of political discourse in the U.S. I believe I have mentioned that I've been OD'ing on NPR due to my (involuntary) commute. Last night they featured a fawning, slavering profile of Grover Norquist, dedicated to fully explaining, on his own terms, who he is and what exactly he thinks he is doing. The only controversy the story sets up is whether Norquist deserves the credit for the Republican allergy to taxes, or whether he just reflects the zeitgeist. The only dissenting voice was three seconds from some dupe at a progressive think tank who complained that he doesn't distinguish between closing tax loopholes and raising tax rates.

That's true, he doesn't, but is that really the only thing that's wrong with his crusade against taxation? NPR gives him the last word (well, not quite the last word -- Morning Edition today featured a long, deferential interview with him):

To Norquist, it all comes back to the "less than" symbol. His goal is not to perfect the tax code. He doesn't aspire to make government work better. For him, tax cuts are a means to the end of shrinking government. "Our job," he says, "is to make people free."

This is indeed the central premise of conservative ideology: that the only institution capable of depriving us of our "freedom" is government, that less government equals more freedom, and so less government should be the aspiration of people who want to be free. Politicians will step up to defend individual government programs and actions -- including conservative politicians who want massive military spending and taxpayer subsidies for their corporate sponsors -- but hardly anybody speaks out in public against the premise.*

Here's a suggestion. Get your head out of the place where the sun don't shine and look around at the real world. The prosperous democracies to which most Americans would presumably like to compare ourselves all have certain things in common: higher tax rates than in the U.S., particularly on the wealthy; and more activist government, including various schemes to provide universal health care; and less economic inequality. Do their people consider themselves less free than us? Is there any discernible sense in which they are in fact less free? Please explain how.

Look, in contrast, at those countries that have the weakest central governments, that don't collect any taxes at all from wealthy people, and where there is essentially no governmental regulation of private enterprise. That would be places like Sudan, Somalia, Afghanistan. Those represent the Grover Norquist/Tea Party version of paradise.

Tell me what I'm missing.

* NPR's slavish devotion to Norquist seems particularly odd. I get the feeling they think that if NPR slobbers all over these people, they'll stop accusing NPR of having a liberal bias and will let them keep their federal funding. Why does that seem unlikely?

Thursday, July 14, 2011

A gang of robbers walks into a bank. The gang leader is named -- let's call him, oh, I don't know, how about Whitey McOrange? Somehow that makes sense, you figure it out.

He has a bomb strapped to his chest. He announces, "Give me all the money in this bank or I'll set off this bomb and destroy the whole bank." The bank manager comes out of his office and says, "I'll tell you what, I'll give you 80% of the money in the bank if you'll promise not to set off the bomb. I need the other 20% to take care of the widows and orphans."

The gang refuses any compromise and demands the full 100%. Reporters show up to cover the standoff and they start writing stories about how sad it is that both parties can't act like adults and come to a reasonable agreement. The bank manager isn't doing enough to meet Whitey halfway at least by giving him 99% of the money.

The bank manager points out that no matter what, Whitey isn't going to set off the bomb because that would kill Whitey and his gang and anyway, their own savings are in the same bank. So the gang members start telling the reporters that the bank manager is engaging in inappropriate threats and everybody knows the bomb will actually be harmless so why doesn't the bank manager stop trying to scare people and just hand over the money?

The reporters nod and look into the camera declaim, more in sorrow than in anger, that Whitey is representing the interests of his gang members, while trying to solve the very serious problem posed by the bomb, and the bank manager is acting like a dick.

Then the deadline passes and Whitey sets off the bomb. . . . It's the bank manager's fault.

If we truly want to rein in spending on health care and reduce the federal budget deficit, the right thing to do is to lower the age of eligibility for Medicare. Actually lowering it to the moment of conception would be the best thing to do, but let's just say we lower it to 60. Below 65, you'd have to buy in. Medicare figures out what it would cost to provide people in that age range with Medicare, and that's your premium. If you already get employer provided insurance, your employer can offer Medicare as an option, paying whatever they already pay toward your health insurance. If you like the deal -- based on your premium share, co-pays and deductibles -- you can go for it. If not, keep your Blue Cross/Blue Shield. If you don't have employer-provided insurance, and you can come up with the premium, it's an option for you. Since you'll be eligible for the ARRA subsidies if your income is moderate or low, it may well work -- and it will be your best option because it's cheaper than private insurance that offers the same benefits!

Yes, there is moral hazard. Medicare doesn't do medical underwriting, so people who have more need of health care would be more likely to sign up. But think about it -- unless they die, they're going to hit the Medicare roles in a year or two or three, and then we'll have to pay to deal with their problem, which will likely be worse and more expensive -- unless of course Medicaid is already paying for it. Right now, when people hit 65, they suddenly show up with all sorts of neglected, untreated conditions that would cost less to treat if they'd been dealt with earlier.

Meanwhile, Medicare now has a larger beneficiary and revenue base, so it can spread its fixed costs over more income. And, with appropriate changes to the law and regulations, it can use its market power to make health care even cheaper and better. Here's a no-brainer example. Using generic instead of brand name drugs for blood pressure control reduces the cost from $52,983 per quality-adjusted life-year to $7,753 -- and just possibly there's actually an almost unheard of net savings, in health care costs because you avoid kidney disease, heart disease, and strokes. All you need is for Medicare to have the legal authority -- which it doesn't now have -- to establish a formulary for Part D in which generic drugs must be prescribed for this purpose unless the physician can make a credible, evidence based case why a brand name is needed. (Which in this case will be impossible, basically.) And note that if we get people's blood pressure controlled at age 60 instead of waiting till they're 65, Medicare won't be paying for all those kidney transplants and stroke rehabs.

Now, the "president" could say all this, and a whole lot of other wonderful true stuff, instead of retransmitting Republican lies and totally buying into the utterly bogus rhetoric about the deficits and the economy. But he doesn't. I assume it's because he's a spy.

The funny thing, though, if you read the CNN report, is that there isn't any particular reason why we keep setting these high temperature records. Yes, there's a high pressure system over the plains, but that happens quite commonly. In the past, when it's gotten hot, it hasn't gotten this hot. So why is it hotter now than in the past? Any guesses?

For Peter Vandermeersch, editor-in chief at the traditionally conservative daily NRC Handelsblad in Rotterdam, The Netherlands, there is no debate about climate change. “Absolutely, that’s a given”, he said. “The conviction has grown that climate change does exist, and that humans play a major role in how it evolves.”

“There’s almost no discussion about it”, agreed Wouter Verschelden, editor-in-chief at the progressive daily De Morgen in Brussels, Belgium. “The nonbelievers have been marginalized, and they aren’t taken seriously anymore. We don’t have to convince our readers anymore of the fact that there is climate change, and that it’s caused by humans.”

According to Vandermeersch and Verschelden, who are both alumni of Columbia University’s vaunted Journalism School in New York, American news media still make the mistake of giving climate skeptics a disproportionate voice, and perpetuating a debate that has long been settled among scientists.

“In a sense, you’re lying to your readers,” says Verschelden. “You’re creating a ‘he said, she said’ story, and looking for an argument that just doesn’t always exist.”

Go ahead and read the whole thing. Keep in mind it's not just climate change -- every outlandish claim some extremist politician makes, from death panels to federal spending as the cause of unemployment -- gets transcribed with total credulity. The story is that the person said it. It would be unethical for a journalist to point out that it isn't true.

Here's the simple background. "Cancer" is not one disease, it's an inclusive term for defects in the regulation of cellular reproduction in which abnormal cells can proliferate to sites in the body beyond their point of origin. (I just made that up but I hope most specialists will say it's good enough for a blog post.) Cell growth and replication are governed by genes, so ultimately these are the result of genetic abnormalities. In addition to losing the usual regulatory processes that keep cells specialized to the correct form, dividing only when they should, and staying where they belong, tumors need to recruit blood supply, and evade immune system mechanisms that can kill abnormal cells, and avoid fail-safe mechanisms that cause abnormal cells to kill themselves, among other problems.

There are innumerable different genetic changes that can accomplish (if that's the right word) these results, and various phenotypic strategies that can result. Therefore, a drug that effectively suppresses cancer cells in one case may not work in another, because it's targeting some specific feature that some cancer cells have and others don't. And so researchers are looking for ways to identify the specific characteristics of specific cancer cells that make them open to attack by equally specific agents.

It sounds good but don't get too excited. This can actually be viewed as bad news. There isn't going to be a big announcement one day that somebody has found the cure for cancer, followed by a super-duper-mega-hyper Nobel Prize. Cancer is actually a gazillion different diseases -- even cancers that start in the same kind of tissue, such as breast cancer or liver cancer, are each dozens of different diseases or maybe even an indefinite number. So the best you can hope for is incremental progress, finding ways of knocking them down one at a time.

And it gets worse. Cancer cells not only reproduce abnormally, their messed up regulatory mechanisms mean they mutate at a high rate. Which means that cancer cells can evolve resistance to drugs that are initially effective. Meaning that most strategies won't produce a cure, but will only hold the cancer in check for a while.

So, fraud or no fraud, unless somebody comes up with a whole new category of idea, we're going to keep spending billions on research and treatment and we're going to keep getting slightly better results for limited numbers of patients with each hard won advance. And the patients who can benefit are also going to be limited to the ones who are lucky enough to be affluent enough to purchase health insurance, or live in rich countries that provide it for them. Which means that everybody is paying for it. But -- each advance means that cancer treatment gets more expensive, because there are more patented, highly expensive treatments to be applied, each of which buys only a limited amount of time before you go on to the next one, if you're lucky.

Obviously, this can't go on indefinitely. But where does it stop, and how? Nobody even wants to think about it, apparently.

Thursday, July 07, 2011

So there goes one more example of idiocy in defense of Ayn Randism, in this case the claim, now debunked by SCIENCE!, that health insurance doesn't actually benefit poor people. What's weird, or course, is that we actually needed a study to prove this point.

Alas, I fear it is too late for the light of reason to guide us from the dismal swamp of greed and resentment into which we are sinking like a mammoth in tar.

I'll be honest with you -- I'm actually terrified right now. The Republicans have a plan -- destroy the U.S. economy, and sweep into power in 2012 on a tide of demagoguery and fear. And it might just work. And then ...

Wednesday, July 06, 2011

I guess I'm confused or naive or something, but I'm having a very hard time figuring out who the constituency is for the lunatic party that currently controls the U.S. House of Representatives. It's obviously an oversimplification to say that it's billionaires.

Think about it. Failure to raise the debt limit will be a catastrophe for Wall Street. Slashing Medicare and Medicaid benefits will hurt old and sick people, sure, but also drug companies and the very wealthy and powerful for-profit hospital and nursing home chains, not to mention physicians who as a class are quite affluent and some of whom are very wealthy. Transportation infrastructure -- highways, bridges, airports -- is essential to all sorts of businesses, including the auto industry, as well as directly paying construction companies, and manufacturers of heavy equipment. (Yes, that industry is one where the U.S. still dominates -- Caterpillar and John Deere make the really big stuff in the U.S.A.) Atrios "can even remember when the highway lobby had clout."

Large reductions in federal spending, on the scale they are now talking about, aren't going to come out of food stamps (for which the real constituency is the Republican friendly farm lobby, not poor people, anyway); or the budgets of regulatory agencies. As David Leonhardt points out, the business lobbies don't actually want the federal government to cut spending. Yes, they don't want to pay taxes either, which means they actually want the deficit to increase, but the Republicans aren't just leaving it at that, they are insisting on massive spending cuts. On whose behalf are they acting? I'm not getting it.

Tuesday, July 05, 2011

ONONDAGA, N.Y. (AP) — Police say a motorcyclist participating in a protest ride against helmet laws in upstate New York died after he flipped over the bike's handlebars and hit his head on the pavement. . . . State troopers tell The Post-Standard of Syracuse that 55-year-old Philip A. Contos of Parish, N.Y., was driving a 1983 Harley Davidson with a group of bikers who were protesting helmet laws by not wearing helmets. . . . Troopers say Contos would have likely survived if he had been wearing a helmet.

While I'm sure Contos's co-religionists will just say, well, that was his choice to make, but ...

What if Mr. Contos had responsibilities, such as children to support or an elderly parent to care for? Will the state have to assume those responsibilities now?

What if he had suffered a severe brain injury, but lived, and ended up costing the people of New York millions of dollars in Medicaid expenses over the next 20 years or so? Is it really in the interest of liberty for him to have the unrestricted license to put those burdens on others?

I have long insisted here that psychiatric medications should be swallowed only as an act of desperation, but I have to admit even I hadn't fully put the picture together the way Whitaker does. Let me first run down some stone cold facts that he adduces; then I'll talk a bit about his interpretations and point out where there is a bit of room for criticism. Even so, his central thesis remains pretty bullet proof, in my view.

Drug advertisements and reports in popular media have the public pretty well convinced of a basic story about mental illness in general - whether it's depression, so-called bipolar disease, schizophrenia, "anxiety disorder" or basically new diseases like Attention Deficit Hyperactivity Disorder or "social phobia." (ADHD actually maps partly onto an entity that's been recognized for quite a while, as does social phobia, which used to be called shyness. But the medicalization and specific diagnostic criteria for these conditions are recent.) The story is that these are diseases, caused by chemical imbalances in the brain, which are corrected by the appropriate drugs.

This is undeniably false. No consistent abnormalities of neurotransmitters or anything else have been detected in the brains of unmedicated people diagnosed with these various diseases. However, the drugs themselves do cause abnormalities in both the numbers of receptors for, and the production of, particular neurotransmitters, which can be long lasting or even irreversible. So the only reason people with these diseases have these abnormalities is because they have taken drugs which have caused them. That's a cold fact.

The really bad news is that once a person has these drug-induced abnormalities of the brain, stopping the drug causes withdrawal effects, including a rebound of the symptoms of the disease. That's because the abnormalities result from the brain trying to restore normal operation, e.g. reducing the number of serotonin receptors in response to a continual flood of serotonin. So when you stop the drug, you really do have a serotonin deficiency, even though you didn't before, and that makes you sick.

The even worse news is that before the era of psychopharmacology, the various diseases which are now viewed as inevitably chronic and disabling, requiring possibly life-long medication, and which now have millions of Americans on the disability roles, were usually self-limiting. The vast majority of people with depression just got better after a while. As a matter of fact, so did people with schizophrenia, which we have been told to believe is almost inevitably progressive and irreversible. What we now call bipolar disease was very rare, and usually remitted on its own after no more than two or three manic episodes. Now it is disturbingly common, chronic, and devastatingly disabling.

Whitaker's claim is the worst news of all -- that the chronicity of these diseases is largely caused by medications. In fact, bipolar disease, in most cases, is caused initially by antidepressants. Most people with the disease never would have experienced any manic episodes if they hadn't been given antidepressants. The other side effects of these "medications" are equally devastating -- and greatly shorten people's lives.

Ritalin for ADHD is equally pernicious. It makes kids who are a pain to their teachers sit down and shut up, but it doesn't do the children any good. In fact their academic performance does not improve, their physical stature is stunted, and they develop other behavioral and cognitive problems. The drug is not treating the patient, it is treating problems the patient is causing for other people.

Whitaker believes this situation developed because psychiatry was losing its raison d'etre. You didn't need to be an MD to counsel people. But if mental illness is really a biological problem that can be treated with prescription drugs, psychiatrists are back in business. The problem with this is that the drugs were not developed as treatments for any known etiology of disease. Instead researchers observed that they made animals say, docile or hyperactive or whatever; and then they tried them out on people who seemed agitated or depressed. Indeed, agitated people got calmer and depressed people got more hyperactive. So they decided that the disease was caused by a lack of whatever the drugs had to offer and there you are. As Whitaker and others have pointed out, this is like concluding that pain is caused by a morphine deficiency.

The studies that won FDA approval for these drugs were all for short terms. Longer term studies inevitably find that people who are unmedicated do better. Actually a lot better. This is also a cold fact.

So Whitaker's accusation is essentially that billions of dollars have been wasted and hundreds of thousands of lives destroyed by what amounts to nothing more than the most pernicious quackery. It gets even worse as the pharmaceutical revolution has been extended to children. Children are normally emotionally labile, and if they suffer from trauma or neglect they can obviously develop serious emotional and behavioral problems. But now they're being diagnosed right and left with "biopolar disorder" and fed psych meds which are essentially destroying their brains, while their real problems go unrecognized and unaddressed.

Wow.

This is all open to some criticism on a couple of grounds, which basically come down to what is called confounding by indication. People who are not on drugs are doing better either because people who don't take drugs do better; or people who do better don't take drugs. It's hard to tell which, since the longer term studies are observational rather than experimental. And the data from the pre-psychopharmaceutical past are hard to compare with modern epidemiological data because the diagnostic liability was different. Would all of those people diagnosed with schizophrenia in the past have gotten the same diagnosis today? Probably not.

Nevertheless, I will tell you as a regular reader of BMJ that the attitude toward psych meds in Europe is a lot more skeptical than it is in the U.S. In the UK, the first prescription for depression is exercise -- which by the way is highly effective -- and it is now considered that antidepressants are of use only in cases of severe, intractable depression. There are various programs for drug free treatment of schizophrenia which seem to be quite successful. All this tossing people pills for shyness and rambunctiousness just doesn't happen.

But when the first response to somebody who is feeling down in the dumps is to throw anti-depressants at them -- and that is exactly what happens -- we're in a really bad place.

Fortunately, the medical establishment is starting to think twice. Harvard's Joseph Beiderman, the one person most responsible for popularizing the drugging of children, has been dinged for undisclosed conflicts of interest: "After a three-year investigation, Massachusetts General Hospital and Harvard Medical School found that Dr. Joseph Biederman and two other psychiatrists violated conflict of interest rules and, as a result, face sanctions." Whitaker tells us that:

Joseph Beiderman may have been the KOL ["Key Opinion Leader in the parlance of drug marketers] who did the most to help the pharmaceutical industry build a market for its products. To a large extent, juvenile bipolar illness was his creation, and children and adolescents so diagnosed are often treated with drug cocktails Pharmaceutical companies paid Beiderman $1.6 million for his various services from 2000 to 20007 . . . . Beiderman also got [Johnson and Johnson] to pay $2 million to create [a center he runs] at Massachusetts General Hospital. . . . Beiderman has been the Pied Piper of pediatric bipolar disease, and we can see [in a document describing the mission of the center] the future that he was laying out for the children given this diagnosis. They were being groomed to be lifelong consumers of psychiatric medications.

So now he'll have to spend the next two years under somewhat closer supervision, without explaining or admitting in public exactly what the heck he did wrong. That'll teach 'em.

Update: Somebody wants to see the references. Whitaker provides them here. I am reasonably familiar with this literature so my endorsement of certain conclusions is with substantial basis. The basic fact that there is no known etiology for any of the mental disorders under discussion, and no evidence that they result from "chemical imbalances" which are corrected by these drugs, is generally accepted by experts of all stripes, including those who still advocate use of the drugs. It is not by any means a radical or niche opinion.

Friday, July 01, 2011

I'm taking a couple of days off from work in order to have a great time -- specifically, I'm painting my house. This doesn't prevent me from posting here, but it does prevent me from being all serious and well-sourced the way I usually like to be, and maybe that means erratic posting for a while.

I am moved to say, however, that President Obama's problem is that he is not dickish enough. Until Wednesday he had resolutely, courageously, forthrightly absolutely refused to exercise leadership on even the most pressing crises facing the nation. Finally he gets on TV and expresses a bit of irritation with the monolithically dishonest and downright lunatic opposition and the hairhats are all "Oooh, how uncivil."

Listen, what he should have been saying for the past year is really simple. It just about fits on a bumper sticker.

The reason why the United States currently has a large federal budget deficit, and faces growing deficits in the future, is entirely because of the Bush tax cuts and the unfunded Bush wars. It is the fault (with some regrettable Democratic collaborators) of the Republican Congress and Administration of 2001-2005. Period. Let the Bush tax cuts expire and wind up the wars, and the problem goes away. We do not need to cut domestic discretionary spending which is in fact already substantially lower than it is in the European democracies and Canada.

A few more points.

The U.S. currently has the lowest federal tax burden since Dwight Eisenhower was president -- lower than when Ronald Reagan was president. Reagan, by the way, raised taxes, six times, because he was not as irresponsible as the current lunatic Republican party. If we just return to Reagan era tax rates, we'll be in pretty good shape.

It was another Republican icon, Dwight D. Eisenhower, who warned of precisely the situation in which we now find ourselves, with extremely powerful vested interests with the political power to win bloated, useless levels of military procurement, which are not in the interest of national security and are nothing but waste.

Unemployment is not caused by budget deficits. Right now, we have unemployment because there isn't enough demand in the economy for the goods and services that workers produce. Under these circumstances, federal budget deficits are good. We need more spending, not less. That will put the economy on a growth path which will, among other good results, help reduce future deficits.

As long as the government is spending money, it should spend it on worthwhile investments that will further strengthen the future economy. I.e., not weapons (see above), but rather renewable energy technology, transportation infrastructure that will conserve energy use in the future and connect urban neighborhoods with jobs, education and quality food stores (i.e., not more highways), education, and other good stuff that will benefit the people. The so-called Free Market™ does not produce enough of this. And that, by the way, is the true Economics 101.

Finally, raising taxes on rich people does not destroy jobs. Just because they will get to keep $30 million from some effort or transaction, instead of, say, $40 million, does not mean they will stop investing or close down their companies. And if some CEO decides that keeping $30 million a year instead of $40 million makes the whole thing just not worth it and retires to Aruba, I'm sure someone else will be happy to take the job. So cut out the crap.

Finally, the continual growth in health care spending is a real problem. It is not specifically a Medicare problem, in fact Medicare is more efficient than private health insurance, although it is a problem for Medicare, not to mention Medicaid. But the solution is not to take health insurance away from more and more people, or give people crappy insurance that doesn't meet their needs, which is what Republicans want to do. Really. The solution is to spend our health care dollars more wisely. Go ahead, call that rationing. Rationing means to allocate resources justly and efficiently. It's a good word. It's a good thing to do. So let's do it.